individualization strategies for older patients with diabetes elbert s. huang, md mph facp...

Individualization Strategies for Older Patients with Diabetes

Elbert S. Huang, MD MPH FACPUniversity of Chicago

Framework for Studying Individualization of Medical Decisions

General Framework for Glycemic Control Decision

A1C < 8%

A1C <7%

Course of Diabetes with A1C < 8%

Course of Diabetes with A1C < 7%

Health Outcomes

Health Outcomes

Individualization of Medical Decisions

A1C < 8%

A1C <7%

Course of Diabetes with A1C < 8%

Course of Diabetes with A1C < 7%

Health Outcomes

Health Outcomes

A1C < 8%

A1C <7%

Course of Diabetes with A1C < 8%

Course of Diabetes with A1C < 7%

Health Outcomes

Health Outcomes

Subgroup 1

Subgroup 2

Evidence Regarding the Presence of Key Subgroups

Trial in New Onset Diabetes (UKPDS)

Intervention TrialMedian follow-up 10.0 years

Intervention Trial + Post-trial monitoringMedian follow-up 16.8 years

RR=0.88 (0.79-0.99)P=0.029

Conventional

Sulfonylurea/Insulin

Conventional

Sulfonylurea/Insulin

Lancet 1998;352(9131):837-53; NEJM 2008; 359:1577-1589

Trials in Long-Duration of Diabetes ACCORD ADVANCE VADT

Age, mean 62.2 66 60.4

Duration of DM 10 yrs (median) 8 yrs (mean) 11.5 yrs (mean)

A1C comparison 7.5% vs. 6.4% 7.3% vs. 6.5% 8.4% vs. 6.9%

Follow-up time 3.5 years 5 years 5 years

Selected Mortality Results

257deaths/5128 (intensive)

203 deaths/5123

No excessive deaths

More sudden deaths in

intensive arm (11/4) but not

significantN Engl J Med. 2008;358(24):2545-59. N Engl J Med. 2008;358(24):2560-72. N Engl J Med. 2009;360(2):129-39.

Impact of intensive glucose-lowering therapy by coronary calcification (VADT)

Reaven P, et al. Diabetes. 2009 Nov;58(11):2642-8.

Implications of Being Sicker – Expected Benefits of Glucose Control Decline

A. New-onset diabetes

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Level of comorbid illness/functional impairment

Dif

fere

nce i

n q

uali

ty-a

dju

ste

d

days

Huang ES, et al. Ann Intern Med. 2008; 149(1): 11-19.

Reduction in Cardiovascular Risk Associated with A1C≤6.5% by TIBI Subgroup

TIBI Score Unadjusted Hazard Ratio (95% CI)

Adjusted Hazard Ratio (95% CI)

P for interaction

<12 0.58

(0.41, 0.82)

0.60

(0.42, 0.85)

0.036

≥12 0.93

(0.68, 1.26)

0.92

(0.68, 1.25)

TIBI = Total Illness Burden Index

Models adjusted for age and sex

Greenfield S, et al. Ann Intern Med. December 2009;151(12):854-860

Classifying Older Adults with Diabetes by Comorbid Conditions (NSHAP)

0

10

20

30

40

50

0 1 2 3 4 5 6 7 8 9

No. of Comorbid Conditions

Per

cent

of P

artic

ipan

tsClass 1 (n = 326)

Class 2 (n = 149)

Class 3 (n = 33)

Laiteerapong N, Iveniuk J, John P, Das A, Laumann EO, Huang ES. Prev Chronic Dis. 2012 May;9:E100.

Clinical Complexity Groups (HRS)

Health Status Groups Description

A Relatively Healthy Group No comorbidities, or comorbidities constrained to osteoarthritis and hypertension, and with no impairments.

Difficulties with Diabetes Self-Management

Multiple comorbidities and/or any one of the following: mild cognitive impairment, poor vision, and 2 or more IADL impairments.

A Limited Benefit Group Poorest health status, with one or more of the following: moderate to severe cognitive impairment, 2 or more ADL dependencies, and/or residence in a long-term nursing facility.

Blaum CS, et al. Med Care. 2010 April; 48(4): 327-334.

Care Guidelines for Older Patients

California Healthcare Foundation/AGS - 2003

Preventive care Target goals

Non-Frail Frail

Glucose A1C<7% A1C8%

Blood pressure SBP<130 mm Hg

SBP<140 mm Hg

Cholesterol Goals unchanged

Aspirin prophylaxis Goal unchanged

Brown AF, et al. J Am Geriatr Soc 2003;51(Suppl. Guidelines): S265–S280

Kirkman et al, Diabetes Care and JAGS Dec 2012

Tools for Individualizing Diabetes Care in Clinical Practice

Variables/Tools for Guiding Individualization

Individual variables– Age– Duration of diabetes – Cardiovascular diseaseMortality prediction models– Comorbidity alone (TIBI, NSHAP)– Comorbidity and functional status (HRS)Diabetes simulation modelsDecision support tools for clinical practice

Comorbidity and Functional Status Index (JAMA 2006;295(7):801-808)

4-year Mortality Index in Older Adults

Risk Factor Assigned Score

Risk Factor Assigned score

Age Comorbidities (continued)

60-64 1 Heart failure 2

65-69 2 BMI<25 1

70-74 3 Current smoker 2

75-79 4 Functional measures

Male sex 2 Bathing 2

Comorbidities Managing finances 2

Diabetes mellitus 1 Walking several blocks 2

Cancer 2 Pushing/pulling heavy objects 1

Lung disease 2

JAMA. 2006;295(7):801-808

Probability of death in 4-years

0

10

20

30

40

50

60

70

0 5 10 15 20

Mortality index score

Per

cent

age

with

sco

re w

ho d

ie

in 4

-yea

rs

Traditional Model of Diabetes Complications

Assign initial patient characteristics

Simulate natural history of diabetes progression according to patient characteristics

Retinopathy Module

Neuropathy Module

Nephropathy Module

Coronary Heart Disease Module

Stroke Module

Mortality Module

Alive

Dead

Advance in disease progression one year

Select next patient

Clinical Decisions:Risk Factor Goals*

Patient Preferences

Clinical Factors**

B

Clinical Decisions: Treatment Selection

A

C D

Conceptual Framework for Personalized Decision Support

Wilkinson, Nathan, Huang. Curr Diab Rep. 2013 Apr;13(2):205-12

Future Directions

Individualization of diabetes care is frequently cited but what it means variesWhat is the best way to individualize care?– No clear consensus on categorization of older

patients– Numerous variables to consider (life expectancy,

duration of diabetes, pre-existing cardiovascular disease)

Need trials of competing algorithms and decision support tools

Thank You

ehuang@medicine.bsd.uchicago.edu